Clinton Plan’s Preventive Care Sparks Healthy Debate : Medicine: Some experts question costs of screening many people to find few who will develop a disease.
It is a well-worn adage, even a cliche. But it serves as the philosophical underpinning of the Clinton Administration’s impending health care reform proposal: An ounce of prevention is worth a pound of cure.
Both President Clinton and First Lady Hillary Rodham Clinton have said repeatedly that their approach to overhauling the nation’s health care system will emphasize preventive medicine--encouraging checkups, screening services and lifestyle changes when people are well.
That approach, its advocates say, not only will save money by exchanging less expensive procedures for more costly ones, it will produce a healthier population that lives longer and suffers less from debilitating disease.
While there is little question that the goal is an admirable and humane one, there are sharp differences over whether the arithmetic is sound.
To be sure, certain measures, such as childhood immunizations, bring indisputable returns, using a relatively low-cost procedure to ward off an array of exotic diseases that are vastly more expensive to treat.
Moreover, it is true that the cost of a mammogram is far less than that of treating breast cancer. But what is less clear is whether substantial amounts of money can be saved by screening large numbers of healthy people to find the few who will develop a particular disease.
The cost-effectiveness of many preventive services has yet to be evaluated in good studies, experts say. Moreover, once people live longer as a result of prevention, will their care be just as costly to the system as it would have been without preventive care? No one really knows.
“No matter what the government does, people are mortal--the longer you live, the more of you there are and the more susceptible you are to getting something,” said Art Caplan, a medical ethicist who worked with the White House health care reform task force.
“That’s why this theory is such a hornet’s nest: Do you swap a heart attack at middle age for Alzheimer’s or Parkinson’s at old age?” he said. “Maybe if you really want to cut services, you should make sure that everybody drinks, smokes a lot, drives fast and carries a gun.”
For Louise B. Russell, an expert in the economics of preventive medicine at Rutgers University’s Institute for Health, Health Care Policy and Aging Research, the answer to the dilemma is clear: “Prevention isn’t going to save money and can be enormously expensive. It’s too much for too few.”
She added: “It’s not right to say that it didn’t cost that much to screen the one person who had the condition. You have to look at everyone to whom the prevention is applied and compare the cost of applying it to everyone. Not everybody who gets screened gets high blood pressure, and not everybody who gets high blood pressure is going to have a stroke.”
Public health experts and the Administration’s health care reformers have argued that the issue should turn less on economics and more on extending lives and making them healthier and free from pain and suffering.
“We should think of prevention as another arm of medical care, not a way to save money,” said a Public Health Service physician who served on the White House task force.
“Perhaps, if you go dollar for dollar treating everybody for hypertension and cholesterol, it might be cheaper to wait until everybody had crushing chest pain and dropped dead in the streets,” said the physician, who requested anonymity. “But that’s not what this is about.”
Russell agreed: “Having already said that prevention doesn’t save money, I also must add that . . . we’re interested in investing in health. We want to make people live longer and healthier.
“Is prevention going to save money? Probably not,” she added. “Is it the right thing to do and what we should have done all along? Sure.”
Russell and others recommend a strategy that involves looking at each procedure and how best it can be used, that is, how often and on whom.
Decisions about how frequently to screen for a condition, what dosage of a drug to use or which risk groups to include can be enormously cost-effective--or enormously expensive. They can cost billions of dollars for very small gains in health--or can reap big benefits for the investment, experts said.
Russell called the Pap smear a good example. Pap smears are used to screen for cervical cancer, an extremely slow-growing and highly treatable cancer when caught early.
Most physicians recommend annual smears for adult women. Russell described this recommendation as an “expensive, low-return investment” because of the nature of the disease. There is no question it is effective in detecting cervical cancer. But because the cancer is so slow-growing, it is probably not cost-effective to screen for it every year, she said.
“Compared with not screening, spending $1 million to provide the test every three years to women 20 through 75 years of age produces a gain of 52 years of life,” she said. “Another $1 million to test women every two years, instead of every three, yields two additional years of life. A third $1 million, to provide annual screening, yields less than one additional year of life.”
The extra gain from each $1-million increment “is small because cervical cancer . . . takes years to progress to the point of threatening life,” she said.
The task force physician said the Administration is well aware of the cost-effectiveness issue and intends to propose covering only those preventive services proved to be effective.
For example, “we think you should pay out of pocket for a mammogram if you’re younger than 50,” she said, noting that studies have not shown the procedure to be as useful in that age group as it is for older women.
The federal Centers for Disease Control and Prevention said the cost of medical care for a woman whose breast cancer is diagnosed early is about one-third to one-half the cost for a woman whose cancer is detected at a later stage.
The CDC cited numerous prevention measures, including lifestyle changes, that have been shown to work “at a reasonable cost,” among them:
* One-time Pap smear screening of low-income elderly women would save 3.7 years of life and $5,907 for every 100 smears performed.
* In 1985, it was estimated that pertussis (whooping cough) vaccinations could save $2 or more for every dollar spent, and immunizations for measles, mumps and rubella could save about $14 for every dollar spent. Immunizing every newborn against hepatitis B could save about $73 million annually. Immunizing people 50 and older against pneumococcal pneumonia could save $141 for every person receiving the vaccine.
* For every dollar spent on prenatal care to low-income, poorly educated women, about $3 is saved in direct medical care costs during that infant’s first year of life.
* A program to increase the use of bicycle safety helmets--including reduced-price sales through schools, required helmet use while cycling in school activities, distribution of promotional materials to cycling clubs and other educational activities--could yield an estimated net saving of $183 million to $284 million annually in the United States.
* Water fluoridation costs about 51 cents per person annually, and $38.25 over a lifetime--about the same as the cost of a dental visit to treat tooth decay.
* For every dollar invested in a smoking-cessation program for pregnant women, about $6 is saved in neonatal intensive-care costs and long-term care associated with low birth-weight children. Also, as a result of the U.S. anti-smoking campaign, an estimated 789,000 deaths were postponed between 1964 and 1985, and an additional 2.1 million deaths will be delayed between 1986 and the year 2000.
The Administration’s reformers said they hope that the impact and application of a prevention approach will extend beyond specific proposals from the federal government.
“You can’t look at this thing as ‘x’ service and ask how much it saves,” said the Public Health Service physician. “What happens to people when they get into a preventive mode with their health? Nobody knows the answer for sure. But it is likely that a society which emphasizes health maintenance ultimately will make less use of technology because people will not become ill early. And that is, in fact, a less expensive society.
“What this Administration is trying to do is change the emphasis on where people access the health system,” she said. “And this will have an impact on the types of clinicians they see and the volume of testing they incur.
“The whole thing may be an economic wash--we don’t know,” she said, adding: “Medicine shouldn’t exist to save money but to preserve health.”
Checking Nation’s Vital Signs
Though many Americans have access to the best medical care in the world, others get little or no care. And for those who do receive care, the costs have skyrocketed. Here are some of the trends often cited as evidence the nation needs to change the way medical care is delivered:
WHERE THE MONEY COMES FROM . . . Private health insurance: 35% Out of pocket: 20% Medicare: 17% Medicaid: 11% Other government: 13% Other private: 4% +
. . . AND WHERE IT GOES Doctor services: 19% Hospital care: 38% Nursing homes: 8% Drugs and nondurables: 8% Others: 27% +
THE GROWING COST PER PERSON . . . ‘93: $3,380 *
+
. . . IS REFLECTED IN RISING BURDEN ON NATION (health care spending as a percentage of gross domestic product) ‘93: 14.4% * +
SUCH SPENDING COMPARES POORLY TO OTHER NATIONS (Health spending as a percentage of GDP, 1991 figures) U.S.: 13.2% Canada: 10.0% Germany: 8.5% Japan: 6.5% Britain: 5.4% +
MEDICARE’S GROWING NUMBERS (numbers of people on Medicare, in millions) ‘92: 31.6 * projections
Sources: OECD Health Systems: Facts and Trends, Health Care Financing Administration, American Medical Assn., UCLA School of Public Health, California Medical Assn., Health and Human Services
